Tension pneumothorax resident survival guide: Difference between revisions

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<span style="font-size:85%;color:red">Tension pneumothorax requires '''immediate''' intervention.  Diagnosis should be made based on the history and physical examination findings.</span> <br>
<span style="font-size:85%;color:red">Tension pneumothorax requires '''immediate''' intervention.  Diagnosis should be made based on the history and physical examination findings.</span> <br>


❑ [[Dyspnoea]] (sudden in onset)<BR>
❑ [[Dyspnoea]]<BR>
❑ [[Pleuritic chest pain]]<BR>
❑ [[Chest pain]]<BR>
❑ [[Cyanosis]]<BR>
❑ [[Cyanosis]]<BR>
❑ [[Sweating]]<BR>
❑ [[Sweating]]<BR>
❑ [[Anxiety]]<BR>
❑ [[Anxiety]]<BR>
❑ [[Fatigue]]<BR>
❑ [[Fatigue]]<BR>
Air way pressure alarm: if on [[mechanical ventilation]]
Decreased [[consciousness]] (in late stages)<br>
❑ Airway pressure alarm<br>
: ❑ If patient is on [[mechanical ventilation]]
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{{familytree | | | | |!| | | | | | | | | }}
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{{familytree | | | | K01 | | | | | K01=<div style="float: Left; text-align: left; width: 40em; padding:1em;"> '''Consider risk factors:'''<br>
{{familytree | | | | K01 | | | | | K01= <div style="float: Left; text-align: left; width: 40em; padding:1em;"> '''Identify precipitating factors:'''<br>
 
(Diagnosis of [[pneumothorax]] is more likely if any of the following is present)<br>
❑ Recent invasive procedures<br>
❑ Recent invasive procedures<br>
:❑ [[Thoracentesis]]<br>
:❑ [[Thoracentesis]]<br>
:❑ [[Central venous catheter]]<br>
:❑ [[Central venous catheter]]<br>
:❑ [[Bronchoscopy]]<br>
:❑ [[Bronchoscopy]]<br>
Cigarette smoking<br>
:[[Pleural biopsy]]<br>
:Risk of pneumothorax is higher in smokers (12%) than non-smokers (0.1%).<ref name="pmid8484388">{{cite journal| author=Abolnik IZ, Lossos IS, Gillis D, Breuer R| title=Primary spontaneous pneumothorax in men. | journal=Am J Med Sci | year= 1993 | volume= 305 | issue= 5 | pages= 297-303 | pmid=8484388 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8484388  }} </ref><br>
[[Mechanical ventilation]]<br>
 
❑ [[Cardiopulmonary resuscitation]]<br>
❑ [[Cystic fibrosis]]<br>
Presence of [[Drain (surgery)|chest drains]]<br>
:16% to 20% of patients with [[cystic fibrosis]] >18 years will experience pneumothorax.<ref name="pmid16100160">{{cite journal| author=Flume PA, Strange C, Ye X, Ebeling M, Hulsey T, Clark LL| title=Pneumothorax in cystic fibrosis. | journal=Chest | year= 2005 | volume= 128 | issue= 2 | pages= 720-8 | pmid=16100160 | doi=10.1378/chest.128.2.720 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16100160  }} </ref></div>}}
❑ [[Hyperbaric oxygen]] treatment<br>
Chest wall trauma </div>}}


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Revision as of 03:06, 24 March 2014

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mohamed Moubarak, M.D. [2]

Synonyms and keywords: Collapsed lung; air around the lung; air outside the lung

Tension Pneumothorax Resident Survival Guide Microchapters
Overview
Causes
Diagnosis
Treatment
Do's
Don'ts

Overview

Tension pneumothorax is a medical emergency resulting from accumulation of air in the pleural cavity. Air enters the intrapleural space as a result of disruption in the parietal pleura, visceral pleura or tracheobronchial tree, this disruption results in the formation of a one way valve which allows the air to enter in the pleural cavity (during inspiration) but prevents its escape (during expiration). Subsequently, pressure inside the pleural cavity rises high enough to cause respiratory and cardiovascular failure. Tension pneumothorax can occur as a result of trauma, ventilation, resuscitation and preexisting lung disease.[1] It should be managed immediately with emergency needle decompression.

Causes

Life Threatening Causes

Tension pneumothorax is a life-threatening condition and must be treated as such irrespective of the underlying cause.

Common Causes

Tension pneumothorax can be a complication of primary, or secondary pneumothorax. The most common causes of tension pneumothorax are:

Diagnosis

Shown below is an algorithm depicting the diagnostic approach of tension pneumothorax based on the British Thoracic Society Pleural Disease Guideline 2010.[1]


 
 
 
Characterize the symptoms:[1]

Tension pneumothorax requires immediate intervention. Diagnosis should be made based on the history and physical examination findings.

Dyspnoea
Chest pain
Cyanosis
Sweating
Anxiety
Fatigue
❑ Decreased consciousness (in late stages)
❑ Airway pressure alarm

❑ If patient is on mechanical ventilation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Identify precipitating factors:

(Diagnosis of pneumothorax is more likely if any of the following is present)
❑ Recent invasive procedures

Thoracentesis
Central venous catheter
Bronchoscopy
Pleural biopsy

Mechanical ventilation
Cardiopulmonary resuscitation
❑ Presence of chest drains
Hyperbaric oxygen treatment

❑ Chest wall trauma
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Examine the patient:

Vital signs

Pulse:

❑ Rate
Tachycardia
❑Strength
❑ Weak

Respiratory rate:

❑ Severe tachypnea

Blood pressure

Hypotension

Focused chest examination:[1]

Inspection

❑ Reduced lung expansion on the affected side
❑ Enlarged involved hemithorax
Jugular venous distension

Palpation

❑ Trachea shifted to the opposite side
❑ Decreased vocal fremitus
❑ Displacement of the apex beat

Percussion

Hyperresonance

Auscultation

❑ Diminished breath sounds on the affected side


 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider alternative diagnoses:

Acute myocardial infarction

❑ Nausea, vomiting, and diaphoresis
❑ Triggered by exercise
❑ Substernal discomfort
❑ Pain radiate to the neck and the arms

Asthma

❑ Expiratory wheeze

Pericardial tamponade

❑ Sharp,stabbing chest pain
Syncope/presyncope

Emphysema

❑ Past history of emphysema

Musculoskeletal pain

❑ Tenderness on palpation
❑ Pain increase with respiration

Rib fracture

❑ History of trauma
❑ Severe tenderness

Pulmonary embolism

❑ Risk factors for thromboembolism
❑ Recent fracture
Deep venous thrombosis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Imaging studies:

Immediately proceed to needle decompression in clinically diagnosed hemodynamically unstable patients
Chest X-ray

❑ Diagnostic test of choice
❑ Perform serial chest X-ray every 6 hours on the first day after injury to rule out pneumothorax[2]


Picture courtesy of Wikidoc.org
Left-sided tension pneumothorax

❑ Erect position in inspiration
❑ Air in the pleural cavity
❑ Contralateral deviation of mediastinum
❑ Increased thoracic volume
❑ Ipsilateral flattening of heart border
❑ Mid diaphragmatic depression

❑ Chest CT scanning

❑ For uncertain or complex cases


Picture courtesy of Wikidoc.org
Left-sided pneumothorax. A chest tube is in place-side of chest, the lumen (black) can be seen adjacent to the pleural cavity (black) and ribs (white).
Ultrasonography
❑ Digital imaging

 
 
 
 

Treatment

 
 
 
First aid:

❑ Assess airway, breathing, and circulation (ABC)
❑ Immediately cover sucking chest wounds with an occlusive or pressure bandage
❑ Give 100% oxygen [2]

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Manage the patient with a multidisciplinary team:
❑ Consult a thoracic surgeon
❑ Consult a cardiologist
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Emergency needle decompression:

❑ Aseptic preparation

❑ Use two alcohol-based skin disinfectant

❑ Use 14-16 G intravenous cannula
❑ Site

❑ Make sure you are on the diseased side, tension pneumothorax may affect breath sounds on both sides
❑ 2nd intercostal space, midclavicular line
❑ Use 4th or 5th intercostal space mid or anterior axillary line, if initial decompression is failed because of thick chest wall[1]

❑ Listen for gush of air
❑ Leave the cannula in place until bubbling is confirmed in the chest drain underwater seal system
❑ Check chest tubes, as they can become plugged or malpositioned
❑ Don`t repeat needle aspiration unless there were technical difficulties


❑ Watch how to do a needle decompression {{#ev:youtube|UvHJ4pjNh2Q|400|How to do a needle decompression}} Video adapted from Youtube.com

Antibiotic therapy:
First-generation cephalosporin

❑ Give initial parenteral dose to decrease the risk of empyema and pneumonia
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Admit the patient
❑ Refer the patient to respiratory specialist within 24h of admission
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Insert chest drain

❑ Timing of procedures:

❑ Do it during working hours, complications are higher when performed after midnight
❑ Do it immediately regardless the time if emergent

❑ Use image guidance

❑ A recent chest X-ray before the procedure
❑ Standard erect Postro-anterior chest x-ray
❑ Lateral x-rays provide additional information

❑ Ensure aseptic technique
❑ Give adequate analgesia to patients before chest tube insertion, as the procedure is extremely painful
❑ Site: the triangle of safety bordered by

❑ Superiorly: the base of the axilla
❑ Anteriorly: lateral edge of pectoralis major
❑ Laterally: lateral edge of latissimus dorsi
❑ Inferiorly: the line of the fifth intercostal space


❑ Requirments

Written consent
❑ Clean area for the procedure
❑ Competent operator and nursing staff

❑ Equipment required

❑ 1% lignocaine
Alcohol based skin cleanser
❑ Sterile drapes, gown, gloves
❑ Needles, syringes, gauze swabs
❑ Scalpel, suture (0 or 1-0 silk)
Chest tube kit
❑ Closed system drain (including water) and tubing
❑ Dressing
❑ Clamp

Avoid complications:
❑ Pain

❑ Give snalgesia
❑ Give local anesthesia

❑ Intrapleural infection

❑ Use aseptic technique

❑ Wound infection

❑ Use antibiotics prophylaxis

❑ Drain dislodgement and blockage

❑ Do frequent checking

❑ Visceral injury

❑ Use proper insertion technique
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Discharge and follow up

❑ All patients should be followed up by respiratory physicians
❑ Advise to return to hospital if increasing breathlessness develops
❑ Advice to avoid air travel
❑ Advice to avoid diving

 
 
 
 
 
 
 
 
 
 
 
 
 

Do`s

  • Tension pneumothorax diagnosis should be made based on the history and physical examination findings.
  • Serial chest radiographs every 6 hrs on the first day after injury to rule out pneumothorax is ideal.[2]
  • Leave the cannula in place until bubbling is confirmed in the chest drain underwater seal system
  • Suspect tension pneumothorax with blunt and penetrating trauma to the chest
  • Differentiate tension pneumothorax from pericardial tamponade, and myocardial infarction.
  • Suspect tension pneumothorax in patients on mechanical ventilations, who have a rapid onset of hemodynamic instability or cardiac arrest, and require increasing peak inspiratory pressures.
  • Check chest tubes, as they can become plugged or malpositioned and stop functioning.
  • Give adequate analgesia to patients before chest tube insertion, as the procedure is extremely painful.
  • Refer the patient to respiratory specialist within 24h of admission.

Dont`s

  • Don`t start using chest radiograph or CT scan unless in doubt regarding the diagnosis and when the patient's clinical condition is sufficiently stable.
  • Don`t use large bore chest drains.[1]
  • Don`t repeat needle aspiration unless there were technical difficulties.

References

  1. 1.0 1.1 1.2 1.3 1.4 1.5 MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group (2010). "Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010". Thorax. 65 Suppl 2: ii18–31. doi:10.1136/thx.2010.136986. PMID 20696690.
  2. 2.0 2.1 2.2 Sharma A, Jindal P (2008). "Principles of diagnosis and management of traumatic pneumothorax". J Emerg Trauma Shock. 1 (1): 34–41. doi:10.4103/0974-2700.41789. PMC 2700561. PMID 19561940.


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